2.0 Analysis 2.1 Exchange of Information--STATENDAM To be effective, the master or OOW/pilot dialogue should be initiated with the formal presentation of the pilot card and examination of the bridge poster, and continued through informal discussion about the capabilities of the ship, status of relevant equipment, the intended pilotage, and any pertinent regulations or special conditions. Performed in this manner, the exchange of information removes doubt as to the intended course of action of any party to the exchange. Conflicting information collected in this instance does not make it clear whether or not a full exchange of information took place. However, it is evident that the exchange did not take place at one session or in the formalized manner necessary for a complete understanding of the intentions of the vessel's master/OOW and the pilot. 2.2 BRM--STATENDAM The working relationship between ship masters/watchkeeping officers and pilots is a crucial factor in the safe navigation of cruise ships in the inside passages and coastal waters of BritishColumbia. Because of the different maritime background (experience and training) of BCCP pilots and the masters and officers of these cruise ships, it is essential that the skills of each person be combined in the working relationship of a bridge team. Within the team, it is also essential that the different tasks required for the safe navigation of the vessel be allocated to the person best equipped/experienced to carry them out and that each person not carry too much workload. Although the principles of BRM are well known and have gained wide acceptance in the shipping industry, the non-application of these principles was a major factor in the development of the close-quarters situation. Of the bridge team, only the master had been trained in BRM, but he neither interfered with, nor challenged, the pilot's decisions until after the vessel had been committed to a course which led her into danger. Further, because arrangements were not made to share the workload/tasks involved in navigation and in communications, members of the bridge team, including the pilot, were not effectively engaged on those tasks in which they were most experienced and which were fundamental to safe navigation. Because the master was preoccupied with the vessel's scheduling (in this instance her ETA at Seymour Narrows), he was concentrating on the vessel's speed and, at the time the vessel was rounding Chatham Point, ordered the OOW to tell the engine-room to reduce the number of generators to three. The effect of this was that, during the initial part of the swing, attention was momentarily diverted from both the rate of turn and the identification of the radar target of the BELLEISLE SOUND about whose intentions they had previously been informed by MCTS. Similarly, the pilot was preoccupied with the vessel's rate of turn, using a method with which he was not familiar. The master, OOW and the helmsman were familiar with the method but the master and OOW were, at least initially, acting upon the need to reduce speed to arrive at Seymour Narrows at a suitable time. The effect was that the pilot, unassisted, chose a rate of turn which could not bring the vessel onto her intended track for the next leg of the voyage. The pilot was not alone in believing that he was best equipped to handle VHF communications; shore-based pilotage personnel also shared this traditional view. The pilot also communicated by handheld VHF which, although equipped with a speaker, was reportedly used in such a way that only he knew what was said in these conversations. It was reported that the pilot was using his radio while starting the turn at Chatham Point which also may have distracted him from the more important decision of establishing the appropriate rate of turn. Had BRM been practised, the whole bridge team could have been kept aware of all information received on the bridge by this means while concentrating on primary tasks. If other members of the bridge team, as well as the pilot, had monitored VHF communications, it is probable that the important information regarding the position and intentions of the BELLEISLE SOUND would have received the attention it required. 2.3 Navigation with a Pilot on Board In general, the non-application of BRM principles may have been influenced by maritime culture, and in particular by the PPA letter given to masters of cruise ships which emphasizes that the pilot must be given the con of the ship. However, the IMO Code of Nautical Procedures and Practices, the STCW, and HAL Operating Regulations all indicate that the presence of a pilot does not relieve the master of his duties and responsibilities and require that the master and/or the OOW closely monitor the pilot's actions and intervene if necessary to assure the vessel's safety. Despite the master's clear right to delegate a part of his authority while retaining overall command, the language of the PPA letter could be construed as intimidating - especially to a master unfamiliar with the working relationships which necessarily evolve from such an apparent contradiction. 2.4 Master/Pilot Relationship The master of the STATENDAM reported that he had full confidence in the pilot before the development of the near-collision situation because there had been no disagreement on the bridge, but he did consider taking over the con when the close-quarters situation developed. However, he did not do so because he felt that the vessel was committed to the orders given by the pilot to avert collision. It would appear, nonetheless, that had the master intervened from the time that it became evident that the STATENDAM was turning too slowly to stay on her preplanned course, it might have been possible to avoid crossing ahead of the tug and tow. 2.5 Factors Affecting the Turn at Chatham Point From the manoeuvring data of the STATENDAM established during trials, it is evident that the vessel had ample room to negotiate the turn at Chatham Point and that the turn was commenced in ample time to come round to the next course which ran mid-channel for the transit of Discovery Passage. There is conflicting information as to the method used by the pilot to alter course before Chatham Point. The OOW reported that the pilot used the rate-of-turn method for all alterations made after receiving a briefing earlier in the watch. The pilot did not recall this briefing and stated that he did not employ the rate-of-turn method until Chatham Point. There is, however, no doubt that the pilot used the rate-of-turn method at Chatham Point. The helmsman was thoroughly conversant with the characteristics of the rudder. Given the prevailing visibility and the maximum speed of 16kn at which large alterations of course could comfortably be made, the vessel's speed (over 17kn) was too high. During the turn, the master apparently became distracted from the manoeuvres at hand by the scheduling requirement to reduce the number of generators. The master also distracted the OOW from monitoring the rate of turn and from radar observations by instructing him to make telephone calls to the engine-room. The result was that the pilot, who was the least familiar with rates of turn, chose the rate. Reportedly, he then became distracted when he called the SKY PRINCESS on his handheld VHF radiotelephone. When he again concentrated on the vessel's rate of turn, he realized that the vessel was not turning quickly enough. Both the master and the OOW, who were familiar with the rate-of-turn method, were not concentrating upon it, as they were otherwise involved. Although the master also carried out an ARPA plot of the BELLEISLE SOUND, he did not immediately bring her approach to the pilot's attention. 2.6 Determination of Risk of Collision STATENDAM The pilot had been informed of the presence of the BELLEISLE SOUND by MCTS, but he did not look out for the vessel as he made the turn at Chatham Point. Reportedly, he was distracted by talking to the SKY PRINCESS on his handheld VHF and by the slow rate of turn in response to the helm order. Even after he became aware of the target, he did not recall that it was likely to be the BELLEISLE SOUND. The positioning of the navigation lights when first sighted led him to believe that it was two fishing vessels. It would appear, therefore, from the facts as reported, that no member of the bridge team gave undivided attention to either the vessel's course alteration or to the approach of the BELLEISLE SOUND, and that there was minimal communication between them concerning these crucial matters. Although MCTS had relayed the movements of the BELLEISLESOUND/RADIUM622 to other vessels and to the STATENDAM, no VHF communication was attempted by the STATENDAM to determine the intentions of the tug/barge. The bridge team did not know the identity of the approaching vessels until they were sighted visually just before the occurrence. BELLEISLE SOUND Although alone on the bridge as the close-quarters situation developed, the master of the BELLEISLE SOUND was aware of the approach of the STATENDAM because he had maintained communications with MCTS; had sighted the vessel rounding Chatham Point; and had observed the vessel's echo by radar. It is most probable that the evasive action he took contributed, in large part, to the avoidance of the collision. However, because the tug did not sound fog signals and the MCTS record does not show that the tug initiated VHF communication before the occurrence, the opportunity to make her presence known to the STATENDAM by these means was lost. 2.7 Transport of Dangerous Goods by Barges in British Columbia Waters Because of their remoteness, some logging and fishing camps in British Columbia depend upon supply by sea, and many of these camps are accessible only by smaller barges. These barges, by virtue of their size and construction, may not be able to comply with the full requirements of the IMDG Code for large crewed ships and the DGSR, especially with regard to the separation of dangerous goods. This problem has been recognized. TC Marine Safety has decided to create a West Coast Industry Working Group to work out the requirements for carrying dangerous goods on oil barges, which will form part of TP11960 Standards and Guidelines for the Construction, Inspection and Operation of Barges that Carry Oil in Bulk. A Board of Steamship Inspection Decision will be made for West Coast compliance, which will later follow the CMAC procedure for national compliance. TC Marine Safety officials have decided that, when the amended Standard is developed, they will commence a plan to board tug/barge units. 2.8 Isolation of Traffic Carrying Dangerous Goods The realities of the transportation of goods, including different categories of dangerous goods, to remote camps and communities in British Columbia by sea are that dangerous goods carried on board smaller barges such as the RADIUM622 cannot be separated as required by the applicable regulations and codes. The IMDG Code is mainly applicable to large, crewed, seagoing vessels in international trade. In other modes of transportation, when dangerous goods (especially different categories of dangerous goods) are transported, an isolation of the vehicle is attempted to reduce the risk and the consequences of an accident or collision. It may be argued that only one class of dangerous goods should be transported on small coastal vessels or barges. While this appears reasonable in principle, it would considerably increase the number of voyages needed, and, consequently, the risk of an accident or incident. Although the tug/barge unit and the STATENDAM both reported their progress to MCTS on the night of the occurrence, the degree of traffic separation necessary for a safe passing was not achieved. It is most probable that more attention would have been paid to achieve a safe passing distance had the type of cargo carried been known by all involved. However, the tug/barge unit had safely passed three other passenger vessels before encountering the STATENDAM. 3.0 Conclusions 3.1 Findings The exchange of information between the master/OOW and the pilots was not conducted in the formalized manner necessary to ensure that the intentions of each were fully understood. Arrangements were not made for the bridge team to share the workload and tasks of navigation and communications in accordance with the principles of bridge resource management (BRM). The members of the bridge team were not effectively engaged in those tasks with which they were individually most experienced. The preoccupation of the master and OOW with scheduling matters diverted their attention from the navigation of the vessel, collision avoidance measures and ship handling. Given the prevailing visibility and the maximum speed of 16knots (kn) at which large alterations of course could comfortably be made, the vessel's speed (over 17kn) rounding Chatham Point was too high. The pilot chose a rate of turn of ten degrees per minute to round Chatham Point but this was insufficient to bring the vessel onto her next planned course at the speed being made good. The chosen rate of turn placed the vessel on the east side of Discovery Passage and into the path of the oncoming tug/barge unit. The master/OOW did not challenge the pilot's handling of the vessel when it became apparent that the vessel was not turning quickly enough to follow her preplanned course. No member of the bridge team gave continuous undivided attention to the approach of the tug/barge unit to determine risk of collision. The MCTS information on VHF, concerning the north-bound progress of the tug barge unit, went unheeded. The bridge team did not recognize a dangerous occurrence was imminent and consequently did not take early action to avoid the developing close-quarters situation. An efficient very high frequency (VHF) watch was not maintained and there was little effective communication between the members of the bridge team. After the occurrence, it was discovered that the vessel's wheel-house voice-logging recorder had malfunctioned for several weeks. The time scales of the vessel's two course recorder graphs were such that they were difficult to interpret, and both were incorrectly set. At the time of the occurrence, pilots from the Pacific pilotage area had not been given structured BRM training. It is most probable that the evasive action taken by the master of the BELLEISLESOUND contributed, in large part, to the avoidance of the collision. The vessel did not have a dedicated look-out in reduced visibility until immediately before the dangerous occurrence took place. The vessel did not sound the required fog signals. The vessel was not in compliance with the applicable regulations for the carriage of dangerous goods. In British Columbia waters, dangerous goods are frequently transported by small tug/barge units which cannot meet the requirements of the International Maritime Dangerous Goods (IMDG) Code and the Dangerous Goods Shipping Regulations (DGSR). According to MCTS records, neither vessel used its VHF bridge-to-bridge radiotelephone to communicate with the other to reach agreement concerning the impending passing situation. Neither vessel reported the dangerous occurrence to the MCTS. Although the Marine Traffic Regulator (MTR) on duty informed other vessels of the position and intentions of the BELLEISLE SOUND/RADIUM622, he did not advise them that the tug/barge unit was carrying dangerous goods. Although equipped with a speaker, the manner in which portable VHF radiotelephones are used by British Columbia Coast pilots may make inter-ship communications so received inaudible to those not in the immediate area. Transport Canada (TC) did not have a BRM training syllabus in place for the training of pilots. The tone of the letter issued by the Pacific Pilotage Authority (PPA) to cruise ship masters could be construed as intimidating. Although equipped with a speaker, the manner in which portable VHF radiotelephones are used by British Columbia Coast pilots may make inter-ship communications so received inaudible to those not in the immediate area. Transport Canada (TC) did not have a BRM training syllabus in place for the training of pilots. The tone of the letter issued by the Pacific Pilotage Authority (PPA) to cruise ship masters could be construed as intimidating. 3.2 Causes The near-collision between the STATENDAM and the BELLEISLE SOUND/RADIUM622 occurred because the slow rate of turn of the STATENDAM placed the vessel on the east side of Discovery Passage in the path of the oncoming tug/barge unit. Contributing to the incident were the reduced visibility in fog and darkness; the pilot's lack of familiarity with the navigational systems of the STATENDAM; and the non-application of bridge resource management principles, especially with regard to the logical division of the workload according to the area of expertise of each member of the bridge team. 4.0 Safety Action 4.1 Action Taken 4.1.1 Carriage of Dangerous Goods Subsequent to this occurrence, several corrective actions have been taken by various agencies as follows: A joint industry and government working group has been set up to review the circumstances surrounding the occurrence and to evaluate the potential risk with respect to the carriage, segregation, and stowage of dangerous goods in restricted waterways. It is understood that the findings of the working group will form the basis for appropriate risk reduction measures, such as making amendments to current regulations, implementing Board of Steamship Inspection decisions, etc. The measures will be incorporated in TP11960, Standards and Guidelines for the Construction, Inspection and Operation of Barges that Carry Oil in Bulk. TC Marine Safety has conducted a number of meetings with West Coast towing companies and the Council of Marine Carriers with a view to solving problems regarding the carriage, stowage, and segregation of different types of dangerous goods in smaller barges such as the RADIUM622. A multi-modal Dangerous Goods Committee has been established within the Pacific region. The objectives of the Committee are to facilitate safe transits of dangerous goods throughout British Columbia, to educate persons on the requirements, and to seek harmonization of the regulations where needed. In consultation with United States operators of tugs and tows (American Waterways Association) that transit the inside passages of British Columbia, the Marine Communications and Traffic Services (MCTS) have also initiated voluntary reporting measures for all of those vessels that transport pollutants or dangerous goods. A voluntary report is also requested from operators of tugs and tows carrying pollutants or dangerous goods for voyages originating in the United States with a destination within British Columbia. Further consultations are planned with the Canadian towing industry to institute similar procedures regarding dangerous cargo. 4.1.2 Incident Reporting Immediately after the dangerous occurrence, TC Marine Safety, Vancouver, apprised the master of the STATENDAM, the pilot who was conning the ship at the time of the occurrence and the master of the BELLEISLE SOUND of their responsibilities including, inter alia, the requirement to report occurrences and the obligation to comply with the International Regulations for Preventing Collisions at Sea,(COLREGS). 4.1.3 Bridge Resource Management (BRM) Training Standards for Pilots Subsequent to TSB Recommendation M95-07 with respect to training and the practice on the use of hand-over procedures, TC, in conjunction with pilotage authorities, has promoted procedures for the formal exchange of information between masters and pilots. TC tabled this recommendation at the May 1996 meeting of the Canadian Marine Advisory Council (CMAC) in Ottawa and at the Simulated Electronic Navigation (SEN) seminar held in Vancouver in August1996. In 1996, the Canadian Shipowners Association arranged with Marine Safety International of Newport, R.I., USA to have their masters undergo BRM training at their facilities. One GreatLakes shipping company, representing Canadian Shipowners Association, approached Transport Canada, Marine Safety (MS) to monitor the course for approval. In February 1996, MS agreed to monitor the course but could not officially approve it since no BRM standard existed. Subsequently, MS prepared a draft BRM policy paper and presented it to the CMAC at its November 1996 meeting. At the May, 1997 CMAC meeting, MS announced the formation of a working group with a mandate to develop a course curriculum in BRM. The course topics include passage planning and execution, error trapping and monitoring, Master/OOW relationship, exchange of information, team work and communication. In November 1997, the working group presented the course curriculum to the CMAC and received approval with a provision that the BRM course be non mandatory. This resulted in the publication of the Training Program in Bridge Resource Management TP 13117. Since then, three schools have received TC Marine Safety's approval, namely: the Marine Institute, St. John's, Newfoundland; Marine Safety International, Newport, R.I., USA; and the Nova Scotia Nautical Institute, Port Hawkesbury, N.S. In May1997, after evaluating the BRM courses available, the PPA began training its pilots in BRM. Training in BRM is being conducted at a facility in Dania, Florida; the same facility is being utilised to train pilots in an ongoing advanced ship-handling course that will include the latest technology used on cruise ships. It is reported most B.C. Coast pilots will have completed the training in 1998.